Healthcare Provider Details

I. General information

NPI: 1740019074
Provider Name (Legal Business Name): SANDRA TISCARENO FLORES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9275 GLACIER POINT DR
STOCKTON CA
95212-3494
US

IV. Provider business mailing address

612 CROW CREEK DR
GALT CA
95632-2182
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-9601
  • Fax:
Mailing address:
  • Phone: 209-712-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: